Fertility issues affect 30-50% of women diagnosed with endometriosis. An important factor to make note of is that endometriosis doesn’t necessarily cause infertility or subfertility. Additionally, it doesn’t mean women with endometriosis are automatically barren and infertile. It does indicate the likelihood that a percentage of endometriosis patients may encounter fertility issues delaying conception(subfertility), or inability to conceive (infertility) due to complications common with the disease. This means patients must understand the truth about fertility issues that arise due to endometriosis complications. Knowledge of these underlying causes can aid in proper diagnosis and treatment options that may increase fertility.

Fertility Issues You’re Unaware of

The underlying factors that contribute to endometriosis fertility issues are many. Chronic inflammation being a major contributing factor. Endometriotic lesions irritate the structures and organs they’re on. This irritation causes the immune system to kick in and release cytokines to heal the body and attack the lesions. However, the body isn’t equipped to heal and remove endometriosis, but the immune system, intelligent as it is, doesn’t understand this and continues working to heal and remove the lesions. Thus, creating the destructive cycle known as chronic inflammation.

Furthermore, this inflammatory cycle wreaks havoc on reproductive processes that facilitate conception and full-term pregnancy. From embryo implantation, neutralizing sperm from fertilizing an egg, and fallopian tube function. These complications account for many fertility issues not discussed in connection with endometriosis, including ovulation dysfunction, irregular periods, scarring, adhesions, and autoimmunity.

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Ovulation Dysfunction

Ovulation is the star of the reproductive process. Conception can not occur unless a healthy egg is released from the ovary. However, the inflammatory environment created by endometriosis causes hormonal imbalance that stalls or halts ovulation. This imbalance disrupts the secretion of specific hormones during the follicular phase that encourage proliferation of healthy eggs and triggering the release of mature eggs for fertilization.

Ovulation dysfunction contributes to subfertility and infertility alike and comes in various forms. Our focus is placed on four specific causes of ovulation dysfunction with endometriosis to be general and brief. These factors are Luteinized Unruptured Follicle Syndrome, Impaired Folliculogenesis, Luteal Phase Defect, and LH Surge Irregularity.

Luteinized Unruptured Follicle Syndrome (LUF)

This phenomenon occurs when the follicle within the ovary fails to rupture and release a mature egg. Despite the follicle failing to release an egg, it continues to respond to the surge of luteinizing hormone. This hormone is responsible for triggering ovulation and beginning the luteinization process. Lutenization is responsible for the creation of the corpus luteum. This will eventually travel down the fallopian tube to become fertilized and implant on the uterine wall.

Additionally, the secretion of progesterone causes the endometrium( uterine lining tissue) to thicken. Therefore, the body continues to go through the menstrual cycle as though ovulation occurred. Another name for this type of fertility issue is anovulation since ovulation was absent and no egg was released.

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Why Endometriosis Increases Risk

There are two specific reasons why endometriosis patients may struggle with this fertility issue. The first reason involves the presence of pelvic adhesions. These adhesions are known to glue organs together and alter their function. Having the ovaries or fallopian tubes adhering to other organs can contribute to this dysfunction.

Additionally, endometriosis’s chronic pain can contribute to increased use of NSAIDs (naproxen sodium and ibuprofen) to manage discomfort. And, studies have shown that NSAID usage can increase the likelihood of LUF transpiring.

How It’s Identified

Typically a fertility specialist will run various tests to rule out other potential causes. If they suspect this may be a cause, they may decide to track ovulation via ultrasound to gain a diagnosis. If it reveals that LUF is indeed a fertility issue, various treatment options can be discussed.

Impaired Folliculogenesis

The failure of follicles within the ovary to proliferate and release a mature egg is a blunt description of impaired folliculogenesis. However, understanding what folliculogenesis is and its role in the reproduction cycle helps illustrate this complication’s severity.

Usually, follicle growth is stimulated by the follicle-stimulating hormone (FSH). Multiple follicles are triggered and undergo various phases in which one follicle produces a mature egg for release. Simultaneously, estrogen levels rise and coax the release of LH, which informs the follicle when it’s time for the egg to burst and begin the ovulation process.

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Contributions to Fertility Issues

Simply put, the follicles’ inability to develop correctly prevents the creation of mature eggs and stalls ovulation. Aside from endometriosis, there is a multitude of underlying issues that contribute to this occurrence. Hormonal imbalance, PCOS, and perimenopause can negatively impact this process. Whenever estrogen decreases and FSH increases, this disrupts estrogen, triggering LH surges to occur and encourage egg release.

Risk of Impaired Folliculogeneisis with Endometriosis

While this impairment is mainly due to declining estrogen levels commonly present for premenopausal/menopausal women. Various treatments provided for patients to relieve negative symptoms can create hormonal imbalances and decrease estrogen levels. Medications that suppress estrogen and cause medical menopause may contribute to this issue when discontinuing medication.

Additionally, surgical procedures in which cysts are removed from the ovary or removal of an ovary can create ovarian dysfunction.  Common symptoms are irregular periods, hot flashes, night sweats, vaginal dryness, and decreased libido making conception difficult. Impaired ovarian function is associated with perimenopause, early-onset menopause, or primary ovarian insufficiency.

Another way endometriosis may cause impaired folliculogenesis is its link to diminished ovarian reserve. This can complicate fertility treatments such as IVF due to the lack of viable eggs. While there’s research indicating endometriosis attributing to DOR, there isn’t a clear link or explanation regarding how or why.

Luteal Phase Defect

Luteal phase defects contribute to fertility issues for infertile and subfertile women with endometriosis. It involves a disruption of the menstrual cycle, specifically the luteal phase- hence the name. Under healthy conditions, the luteal phase occurs after ovulation and prepares the uterine lining, also known as the endometrium, for potential pregnancy by the thickening of the endometrium. This process is crucial because it prepares the lining for the implantation of a fertilized egg.

When this process is disrupted, the ovaries fail to release adequate progesterone, which triggers the thickening of the endometrium. Another reason for the defect is the endometrium failing to respond to progesterone and thickening as it should.

How Endometriosis Contributes to This Defect

As we know, endometriosis is a disease that impacts hormonal balance contributing to estrogen dominance and low progesterone. Additionally, the impact of excess estrogen on the thyroid increases hypothyroidism, which is a co-morbidity of endometriosis. These factors can impact the luteal phase and contribute to fertility issues.

However, it’s difficult for doctors to properly diagnose due to inadequate methods to test for this condition. Furthermore, the connection of luteal phase defects to infertility or subfertility isn’t really understood. There isn’t enough medical research to explain or verify the impact this has on fertility. Which makes body literacy important. Tracking fertility using the symptothermal method in which basal body temperature, cervical mucus, the phases of the menstrual cycle, and fertility cues are tracked on a chart providing a visual of your complete menstrual cycle.

Doing so provides feedback identifying symptoms of a potential luteal phase defect, such as irregular cycle length, shortened luteal phase, and spotting in between periods.

If you’re experiencing these issues, seek a qualified fertility expert or reproductive endocrinologist that has a working knowledge of endometriosis and its’ impact on fertility. They will better understand these potential causes and provide better testing options to diagnose and treat this complication.

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Multiple LH Surges (Follicular Stimulation)

Multiple LH surges contribute to fertility issues when they cause anovulatory cycles, therefore, preventing conception. This event happens when the dominant follicle fails to rupture and release an egg, and the body compensates by releasing another follicle 3-5 days later. In reality, it’s impossible to identify the occurrence of multiple LH surges unless you’re tracking your fertility using the symptothermal method. As mentioned earlier, this method involves tracking your basal body temperature in the morning and cervical mucus on a chart to identify your fertile window, ovulation, and other important information about your menstrual health.

Observing this information allows you to notice multiple spikes indicating the failure of follicle rupture and egg release. Typically the follicle will burst and release an egg after the second or perhaps the third occasion. However, in some cases where this process occurs on multiple occasions and fails, the body will progress to the luteal phase and menstruation.

Multiple LH surges may lead to prolonged cycles and irregular periods. If you’re noticing these issues regularly occurring, speak to your doctor to determine if this is a possible cause. In speaking with your doctor, make sure you’re tracking your fertility and sharing this information with them to improve the diagnostic process and provide clarity.

Scarring & Adhesions

The buildup and growth of endometriotic lesions can lead to scarring in affected areas. Furthermore, they can cause organs such as the ovaries, fallopian tubes, kidneys, and bladder to adhere to each other impairing function. Additionally, this contributes to blockages within the fallopian tubes and ovaries, preventing a mature egg’s fertilization.

Another way lesions and adhesions increase fertility issues is by causing oocyte and ovum dysfunction.  In this instance, the ovaries fail to release an oocyte, preventing the ovum’s pickup and transport.

Diagnosis, Treatment, And Contribution To Fertility Issues

Scarring and adhesions are diagnosed and treated in tandem with endometriosis via an exploratory laparoscopy. However, it’s essential to work with an excision specialist with intricate knowledge of endometriosis that knows what to look for and adequately remove endo-related scarring and adhesions. This is imperative because proper treatment can improve fertility odds and increase success with fertility treatments.

Endometriosis And Autoimmunity

The similarities that endometriosis shares with autoimmune diseases due to immune system dysfunction lead many to question if endometriosis is an autoimmune condition. While this still remains unclear, it’s evident that an autoimmune component involves endometriosis that may contribute to fertility issues.

Additionally, autoimmune diseases are common co-morbidities of endometriosis. Meaning there’s an increased risk of developing an autoimmune disease such as celiac disease, thyroid disorder, inflammatory bowel disease (IBD), or systemic lupus with endometriosis.

Furthermore, autoimmune diseases contribute to immune system dysfunction and diminished ovarian reserve. Both of which are two possible causes of subfertility and infertility.

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Immune System Dysfunction

Describing autoimmune diseases as a condition in which the body attacks both healthy and unhealthy cells and tissues in the body is a simple definition for a complex illness. However, the immune system’s inability to differentiate healthy tissue from unhealthy tissue may increase fertility issues.

Generally, the body will perform the functions necessary to conceive and support life, but immune system issues can hinder this. After fertilization, when the embryo is formed, an imbalanced immune system may fail to recognize it as such and proceed to attack it. Hence, contributing to implantation complications and increased risk of miscarriage.

Diminished Ovarian Reserve

We touched on this complication earlier regarding impaired folliculogenesis. Additionally, it poses a difficulty for those with autoimmune disease and autoimmunity complications. This complication impacts the quality and quantity of eggs, which decreases fertility. Furthermore, it reduces the success rate with fertility treatments such as intrauterine insemination (IUI) and in-vitro fertilization (IVF).

Endometriosis-related autoimmunity and concurrent autoimmune diseases should be diagnosed by a specialist with knowledge and expertise about endometriosis. This can help to determine what treatments and fertility options are available for your specific condition.

The Truth About Fertility Issues And Endometriosis

The truth is fertility issues impact many of us in the endometriosis community, whether it’s subfertility or infertility. Endometriosis alone doesn’t determine a woman’s fertility; it’s the underlying complications created by endometriosis that cause subfertility and infertility. Furthermore, a small percentage of doctors understand the issues mentioned above and their impact on fertility, especially as it pertains to endometriosis. Additionally, many of these conditions are challenging to diagnose due to limitations with testing and a standardized diagnostic process.

This makes becoming educated and well versed on these factors a necessity. Creating a space for transparent conversations with your doctor about these possibilities can help you decide if you’re working with the right medical professional. Finding the courage to seek a specialist with knowledge of endometriosis and its impact on infertility is not an easy feat but necessary to get answers about your fertility.

Doing so may increase fertility odds and provide you with options for the next steps in your fertility journey. However, it’s essential to understand that there are no guarantees when it comes to fertility treatments. Some achieve success and get their rainbow baby and happy ending. While others make peace with a different happy ending and transition to a childfree lifestyle.

Regardless of your choice, knowledge, and awareness increases your ability to advocate for your reproductive health and empowers you to make informed decisions about what’s best for you.

References

1. Healthline Article Understanding and Managing Chronic Inflammation 

2. Medscape Luteinized Unruptured Follicle

3. Oxford Academic  Luteinized Unruptured Follicle Syndrome: Incidence and Recurrence Rate in Infertile Women with Unexplained Infertility Undergoing Intrauterine Insemination 

5. American Journal of Medicine The Menopausal Transition

6. Endofound Can Endometriosis Cause Diminished Ovarian Reserve

7. WebMD Luteal Phase Defect

8. Verywell Family Adhesions, Scarring and Treatment

9. Advanced Fertility Clinic of Texas Do Autoimmune Diseases Affect Fertility?